Suicide

The incidence of suicide attempts peaks during the mid-adolescent years. The topic of suicide is often anxiety-provoking for families, educators, and clinicians to even think about, let alone discuss. Adding to this challenge is the glorified way that suicide is sometimes portrayed in popular culture, including on social media. Completed suicides have a devastating effect on communities and can have a contagion effect that sparks other suicide attempts. Pediatric practitioners are often called upon to provide support and guidance and therefore should have a basic understanding of suicide and how to perform a safety evaluation. The following graphic shows that suicide remains a leading cause of death among individuals ages 10 to 25 years.

(Source: Suicide. NIH National Institute of Mental Health.)

Evaluation

Suicidal ideation and behavior are associated with multiple causes and degrees of risk. For example, it is not uncommon for clinicians to see patients who engage in nonsuicidal self-injury (e.g., superficial cutting) to ground or distract themselves from challenging emotional states. However, this type of behavior does not necessarily indicate an acute risk, intent to die, or need for hospitalization. In such cases, patients can benefit from intervention from a multidisciplinary team focused on distress tolerance and other coping skills (e.g., dialectical behavioral therapy [DBT]). Other patients may experience thoughts of suicide and death that are exclusively ego-dystonic (distressing or disturbing thoughts with no intent to act); these children should be assessed but are typically considered at lower risk.

Risk assessment: The assessment of self-injurious or suicidal thoughts and actions can be complex and nuanced. A risk assessment requires an individualized and comprehensive weighing of factors that increase risk of harm (risk factors) versus factors that decrease risk of harm (protective factors). The risk assessment can be useful to guide management. Some risk factors are static or unchangeable (e.g., a prior history of suicide attempts) and some are modifiable (e.g., current depressed mood). Some risk factors are acute (e.g., a recent significant loss) and some are chronic (e.g., limited social support). Ultimately behavior, including suicide, is never fully predictable. At best, clinicians can assess and attempt to ameliorate or modify risks.

There is no known utility to “suicide contracts” or “contracting for safety” (when a patient agrees by verbal contract to not commit suicide or self-harm). The willingness of a patient to “contract for safety” should not be considered a protective factor.

Screening: It is important to screen children and adolescents for the presence of suicidal thoughts or ideation, plans, and behaviors. Existing scales and questionnaires to gauge suicidality have limited predictive value and should not be relied upon clinically. Asking about suicidal ideation does not increase the risk of suicide attempt or completion. Further, ample evidence indicates that teenagers will, if asked directly, reveal this information. The approach to asking about suicidal ideation depends on the patient’s age and developmental level. The National Institute for Mental Health (NIMH) provides a four-question Ask Suicide-Screening Questions (ASQ) tool. Another commonly used screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS).

Examples of progressive questions about suicide, starting with initial questions appropriate for developmentally younger patients, include:

• Did you ever feel so bad or sad you didn’t want to get out of bed?

• Did you ever feel so bad or sad you wished you could go to sleep and not wake up?

• Did you ever feel so bad that you wished you were not alive?

• Did you ever want to be dead?

• Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?

• Did you ever hurt or try to hurt yourself?

• Did you ever try to kill yourself?

• Did you ever think about or try to commit suicide?

Decisions about when to start asking about self-harm, and how far to proceed, will vary based on child and clinical scenario, always erring on the side of asking more questions (even in young children). All adolescents can (and should) be asked very directly about both self-harm and suicide.

Risk factors for completed suicide include the following:

• prior history of suicide attempts

• psychiatric illness

• stressful life event

• male gender

• substance or alcohol use

• poor parent-child communication

• family history of suicide attempts or completed suicide

• access to firearms

Protective factors against completed suicide include the following:

• future orientation

• help-seeking nature

• religious beliefs

• anchoring important figures (supportive adults, including parents and teachers)

• connection to treatment team

Management

If a child or adolescent screens positive for suicidal ideation, risk and protective factors should be assessed to establish level of risk and guide next steps. Coordination with established psychiatric providers (e.g., therapist, pharmacologist, and psychiatrist) is important if safety concerns arise in the office. These professionals can help complete a risk assessment and, if appropriate, offer more-urgent follow-up. Keep in mind that children who do not have established outpatient psychiatric providers but require this level of care may have difficulty finding available practitioners and face long wait times to schedule an intake appointment.

Studies have repeatedly shown that reducing access to suicide methods (e.g., access to sharps, rope, firearms, or pills) reduces the risk of suicide. Many individuals will not seek an alternative suicide method. Advising families to remove or secure known high-risk methods or those identified by the patient can effectively reduce risk. When suicide means cannot be easily removed or the patient expresses intention to find alternate means, removal from the high-risk situation may be required to reduce risk. This could include staying with a relative, or in high-acuity cases, admission to higher level of care such as inpatient psychiatric hospitals.

Confidentiality: Additional collateral information from a parent or guardian is necessary to fully assess a child’s or adolescent’s risk. Although children and adolescents have confidentiality rights regarding their medical and mental health treatment, safety concerns mandate action, and this includes obtaining information from and discussing safety concerns with those charged with their care.

Acute evaluation: If there is concern that a child may pose an acute risk to harm themselves or others, acute psychiatric evaluation is needed. Acute risks reflect imminent threat, such as active suicidal ideation with a plan to act or inability to identify means to remain safe in the setting. This often requires an emergency department evaluation or alternative resources in some communities (e.g., freestanding psychiatric crisis centers or mobile evaluation teams). Each state has specific laws and codes for transfer of a patient for emergency psychiatric evaluation. If the guardian refuses further evaluation of a child at acute risk, the Department of Child and Protective Services may need to be notified.

Depending on the institution and region, an acute evaluation will be performed by a social worker, nurse practitioner, psychologist, or psychiatrist. The evaluation includes a risk assessment and may result in discharge home without change in treatment, discharge home with increased services or referrals, or admission to a residential or inpatient psychiatric unit.